Research

This study contributes valuable insights into use of medical procedures in the context of maternal care by investigating the impact of maternal death on subsequent C-section rates. Using New York State Inpatient Database from Healthcare Cost and Utilization Project (HCUP SID), I examine the effects of maternal death on subsequent treatment patterns at hospital level. To model the substantial differences in practice patterns across mothers of different medical risks, mothers are categorized into low-, middle-, and high- risk groups based on an aggregate measure of their age, pregnancy complica- tions, and admission type (emergency or non-emergency). Leveraging the randomness of the timing of maternal deaths across hospitals, I estimate the aggregate effects of maternal death and effects by mothers’ risk groups. My findings indicate a 1% increase following maternal death on average, and such effects are driven by a 2% increase in C-section rates among middle-risk mothers. No significant effects are observed among low- and high-risk mothers. This finding is consistent with predictions in prior studies that the appropriate method of delivery is usually evident for mothers at the extremes of the risk spectrum, it is the “marginal” patients that require more physician dis- cretion. I do not find discernible changes in health outcomes including stillborn and complications during labor and delivery, suggesting that the rise in C-section rates is likely a defensive practice. Treatment effects are stronger among physicians with more experience in performing C-section, highlighting the role of physicians’ beliefs about their comparative advantage. Small hospitals (average quarterly admission below 400) exhibit slightly larger increase in C-section rates following maternal death, implying that shocks within smaller networks have larger impacts.

This study examines the short-term impacts of various natural disasters, with a specific focus on large-scale climate events, on fertility in the United States from 1969 to 1988. The research distinguishes between different types of disasters, including hurricanes, storms & floods, tornadoes, and cold weather incidents. I first measure the propensity for each type of natural disaster to occur in every county, then I employ propensity trimming to construct the sample for analysis: I include counties with type-specific disaster propensity score between 0.1 and 0.9. Findings suggest that hurricanes and storms & floods tend to increase fertility rates, with a 0.17% increase in fertility fol- lowing hurricanes within the previous two years and a 0.09% increase in fertility after storms & floods. Conversely, tornadoes and cold weather events are associated with decreased fertility, showing a reduction of 0.19% and 0.16%, respectively. Furthermore, the impact of hurricanes on fertility is driven by economically disadvantaged counties, likely linked to limited access to family planning services. The stronger impacts of cold weather incidents on fertility in poorer counties may be associated with the affordability of heating, a significant factor in mitigating the effects of cold weather. This research contributes to the literature on the fertility effects of natural disasters, highlighting the varying impacts of different disaster types.

A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140–720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51–1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22–2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48–1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15–0.82]; P=0.02).In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

Anticoagulation therapy is commonly interrupted in patients with atrial fibrillation (AF) for elective procedures. However, the risk factors of acute ischemic stroke (AIS) during the periprocedural period remain uncertain. We performed a nationwide analysis to evaluate AIS risk factors in patients with AF undergoing elective surgical procedures. Using the Nationwide Readmission Database, we included electively admitted adult patients with AF and procedural Diagnosis-Related Group codes from 2016 to 2019. Diagnoses were identified based on International Classification of Disease, 9th revision-Clinical Modification (ICD-10 CM) codes. We constructed a logistic regression model to identify risk factors and developed a new scoring system incorporating CHA2DS2VASc to estimate periprocedural AIS risk. Of the 1,045,293 patients with AF admitted for an elective procedure, the mean age was 71.5 years, 39.2% were women, and 0.70% had a perioperative AIS during the index admission or within 30 days of discharge. Active cancer (adjusted OR [aOR] = 1.58, 95% confidence interval [CI] = 1.42–1.76), renal failure (aOR = 1.14, 95% CI = 1.04–1.24), neurological surgery (aOR = 4.51, 95% CI = 3.84–5.30), cardiovascular surgery (aOR = 2.74, 95% CI = 2.52–2.97), and higher CHA2DS2VASc scores (aOR 1.25 per point, 95% CI 1.22–1.29) were significant risk factors for periprocedural AIS. The new scoring system (area under the receiver operating characteristic curve [AUC] = 0.68, 95% CI = 0.67 to 0.79) incorporating surgical type and cancer outperformed CHA2DS2VASc (AUC = 0.60, 95% CI = 0.60 to 0.61). In patients with AF, periprocedural AIS risk increases with the CHA2DS2VASc score, active cancer, and cardiovascular or neurological surgeries. Studies are needed to devise better strategies to mitigate perioperative AIS risk in these patients.